Comparison of patients with and without mental disorders treated for suicide attempts in the emergency departments of four general hospitals in Shenyang, China

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General Hospital Psychiatry 32 (2010) 549 – 555

Emergency Psychiatry in the General Hospital The emergency room is the interface between community and health care institution. Whether through outreach or in-hospital service, the psychiatrist in the general hospital must have specialized skill and knowledge to attend the increased numbers of mentally ill, substance abusers, homeless individuals, and those with greater acuity and comorbidity than previously known. This Special Section will address those overlapping aspects of psychiatric, medicine, neurology, psychopharmacology, and psychology of essential interest to the psychiatrist who provides emergency consultation and treatment to the general hospital population.

Comparison of patients with and without mental disorders treated for suicide attempts in the emergency departments of four general hospitals in Shenyang, China☆,☆☆ Bo Bi, M.D., Ph.D.a , Jianhua Tong, M.D.b , Li Liu, M.D.a , Shengnan Wei, M.D.a , Haiyan Li, M.D.a , Jinglin Hou, M.D.a , Shanyong Tan, M.D.a , Xu Chen, M.D.a , Wei Chen, M.D.a , Xiaoju Jia, M.D.a , Ying Liu, M.D.a , Guanghui Dong, M.D., Ph.D.c , Xiaoxia Qin, M.D.a,⁎, Michael R. Phillips, M.D., Ph.D.d a

Department of Psychiatry, First Affiliated Hospital, China Medical University, Shenyang, Liaoning 110001, PR China b Department of Scientific Research, First Affiliated Hospital, China Medical University, Shenyang 110001, PR China c Statistics Center, School of Public Health, China Medical University, Shenyang 110001, China d Shanghai Mental Health Center, Shanghai Jiao Tong University School of Medicine, Shanghai 110001, China Received 30 January 2010; accepted 8 June 2010

Abstract Objective: Compare the sociodemographic and psychological characteristics of suicide attempters admitted to emergency departments of general hospitals in China that do and do not meet diagnostic criteria for mental disorders. Methods: The Structured Clinical Interview for DSM-IV, the Suicide Ideation Scale, the Hamilton Depression Rating Scale and a quality of life measure were administered to 239 consecutive suicide attempters who were treated in the emergency departments of four randomly selected general hospitals in Shenyang. Results: Among the enrolled subjects, 166 (69.5%) met diagnostic criteria for a current mental disorder. Among these 166 subjects, 62.7% had mood disorders, 14.5% had anxiety disorders, 10.8% had psychotic disorders and 3.6% had substance use disorders. The 73 suicide attempters without a mental disorder were younger, had higher levels of impulsiveness and were more likely to have ideas about being rescued. Multivariate logistic regression analysis identified the following independent predictors of having a current psychiatric disorder in the suicide attempters: female gender (OR=3.67, 95% CI=1.23–10.91), more than 6 years of formal education (OR=1.19, 95% CI=1.04–1.36), a higher score on the suicide ideation scale (OR=1.01, 95% CI=1.00–1.03), a higher score on Hamilton depression rating scale (OR=1.26, 95% CI=1.16–1.37) and a lower score on the quality of life scale (OR=0.75, 95% CI=0.63–0.90). Conclusion: The prevalence of psychiatric disorders in suicide attempters in emergency departments of urban China is lower than that reported in most western countries. Suicide attempters with and without mental illnesses are distinct on a number of important dimensions. Mental health assessment and appropriate discharge planning for patients treated in emergency departments for suicide attempts are crucial components of comprehensive suicide prevention efforts. © 2010 Elsevier Inc. All rights reserved. Keywords: Attempted suicide; General hospital; Emergency department; Psychiatric disorders

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The sponsor did not participate in the design of the project, in the conduct of the study or in the preparation of the manuscript. ☆☆ None of the authors have a conflict of interest. ⁎ Corresponding author. Tel.: +86 24 8328 2184. E-mail address: [email protected] (X. Qin). 0163-8343/$ – see front matter © 2010 Elsevier Inc. All rights reserved. doi:10.1016/j.genhosppsych.2010.06.003

1. Introduction Suicide in China is an urgent public health problem. On the basis of analyses completed by the World Health Organization, the combined category of neuropsychiatric

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conditions and suicide accounted for more than 20% of the total burden of illness in China in 2004 [1,2]. Nonfatal suicidal behaviors are important because they are among the most powerful predictors of subsequent suicide deaths [3–6]. Previous studies report substantial overlap in the characteristics of persons who make medically serious suicide attempts and those who die of suicide [7,8]. Although the etiology of suicide is not well understood, numerous studies have shown that the presence of mental disorders is one of the strongest risk factors for suicide attempts and deaths [9]. Recent studies suggest that mental disorders are equally predictive of suicidal behavior in developed and developing countries, but the strongest predictors of suicide attempts in developed countries were mood disorders, whereas in developing countries impulse-control, substance use, and posttraumatic stress disorders were most predictive [10]. In China, a national case-control psychological autopsy study reported an overall rate of mental disorders among completed suicides of 63%, which is much lower than the rate of 90% reported in psychological autopsy studies from other countries [11,12]. The prevalence of mental disorders among suicide attempters in China is uncertain because few of the studies of suicide attempts in emergency departments have employed well-defined diagnostic criteria for mental disorders. There are, moreover, few comparisons of the attempters who do and do not have mental illnesses. Identifying the prevalence of mental disorders among suicide attempters and the similarities and differences between attempters with and without mental disorders is a crucial step to developing targeted strategies for treating high-risk patients. The purpose of the current study is to identify the prevalence of mental disorders in suicide attempters treated in general hospital emergency rooms in China and to compare the characteristics of suicide attempters with and without a current mental illness. 2. Methods 2.1. Designs and setting Individuals treated for suicide attempts (reported by the patient or family members) in the emergency departments of 4 tertiary-level general hospitals in Shenyang (a city with a population of 6.9 million residents), Liaoning Province, in northeastern China were enrolled in the study. The hospitals were randomly selected from all tertiary general hospitals located in Shenyang using a random number table. All individuals who came to the emergency rooms after having made a suicide attempt were identified and approached by a trained research assistant. Subjects who were 15 years of age or older, who were able to understand the study procedures, who had at least one contact persons (to enable follow-up), and who provided written informed consent were enrolled. The study was approved by the Institutional Review Board of the China Medical University.

2.2. Subjects and assessment During the enrollment period, from June 2007 to January 2008, 403 suicide attempt episodes were treated at the target emergency rooms. In 366 instances the individuals met criteria for inclusion in the study, but seven of the cases were repeat attempts during the enrollment period so only the first episode was considered. Among the 359 different patients, 29 were not approached by the research team (primarily because they left the emergency room before the researchers could arrive), 90 refused to participate, 1 did not provide all of the data needed for analysis, and 239 (59.3%) completed the full evaluation. There were no statistical differences by gender (P=.715), age (P=.971) or years of education (P=.069) between the included and excluded patients. The 239 individuals and their accompanying family members were independently interviewed by two trained researchers. The comprehensive suicide attempt interview schedule used includes several components that took 2 hours to complete: (1) a detailed structured questionnaire assessed the patients sociodemographic characteristics (age, gender, employment status, marital status, residence, annual income of family, educational level, religious beliefs), the characteristics of the attempt (method of self-harm, alcohol use at the time of the episode, reported motive, time considered suicide before acting, suicide note, help-seeking prior to attempt) and self-reports of prior attempts or of suicidal history among family members or associates; (2) the Beck 19-item Scale for Suicide Ideation [13] evaluates the intensity of patients' attitudes, behaviors, and plans to commit suicide. Each item consists of three options graded 0-2 according to the intensity of the suicidality; (3) the 24-item Hamilton Depression Rating Scale [14,15]; (4) a quality of life rating scale covering the month prior to the attempt. Respondents assess six characteristics of the attempter (physical health, psychological health, economic circumstances, work, family relationships and relationships with no family associates) on a scale of 1 (very poor) to 5 (excellent). (5) Psychiatric diagnosis was made according to the Diagnostic and Statistical Manual of Mental Disorders, fourth edition, as assessed by the Structured Clinical Interview for DSM-IV Axis I Disorders (SCID). The Chinese translation of the SCID has been shown to be reliable and valid [12,16–19]. This version of the SCID allowed for the inclusion of “not otherwise specified” (NOS) categories of illness for subjects who had clinically significant symptoms combined with social dysfunction but did not meet full criteria of a specific disorder (which is fairly common in China), and for the recording of multiple diagnoses ranked according to clinical importance. The six psychiatric researchers who participated in the study attended a 4-week training course in the use of the SCID; their interrater reliability at the end of training using 16 taped interviews of different types of patients was excellent (intraclass correlation coefficient=0.95).

B. Bi et al. / General Hospital Psychiatry 32 (2010) 549–555

2.3. Data analysis The sociodemographic and clinical characteristics of suicide attempters with and without a DSM-IV illness were compared. To examine the mean differences in the study variables i.e. age, gender, employment status, marital status, residence, self-reported past history of self-harm, any family history of suicide, impulsive suicide attempts between the two groups, we used a frequency distribution, Student's t test, chi-square test and Fisher's Exact test with the assistance of a computer statistical package called SPSS for Windows Version 11.5 (SPSS, Chicago, IL, USA). The critical level of statistical significance was set at 0.05 and the analysis was two-tailed. A logistic regression model examined factors associated with a psychiatric diagnosis among suicide attempters, with presence of a psychiatric diagnosis as the dependent variable. Independent variables in the model included age; years of education (dichotomized as b6 of ≥6 years); gender; religious beliefs and previous episodes of suicide attempts, self-rescue, suicide notes, funeral arrangements, the suicide ideation, depression and the life quality. First, we entered all eleven variables into unconditional logistic regression analyses. The significant independent predictors from the analyses were then selected for possible use in the model. We tested forward (conditional) inclusion of variables in the logistic regression equation. Our model included eleven predictors and based on complete data 239 suicide attempts. Statistical significance in the logistic regression model was assessed using the Wald statistic and the 95% confidence intervals were computed using the Gaussian approximation to the log likelihood of the rate [20]. 3. Results 3.1. Sociodemographic characteristics of suicide attempters A comparison of demographic characteristics for each group is shown in Table 1. Of the 239 patients, 186 (77.8%) were female and 53 (22.2%) male. The majority were Han ethnic group (n=222, 92.9%). Attempted suicide was by self-poisoning in 220 cases (92.1%).Fifty-eight patients (24.3%) had a history of previous suicide attempts. The mean age of the patients who had attempted suicide was 32.5 years (S.D.=14.0). The patients with and without psychiatric disorders were similar in terms of gender, educational level, religious beliefs and annual family income but were different in terms of age, marital status, employment status and living situation. Compared to attempters without a mental illness those with a mental illness were older, more likely to be divorced or widowed, more likely to be unemployed and more likely to be living alone. 3.2. Characteristics of the suicide attempters The most common method of attempted suicide was self-poisoning in both the groups with and without

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Table 1 Socio-demographic characteristics of suicide attempters Crude frequency and % Based on results of SCID exam (n=239) Without any psychiatric disorders n% Age group 15–24 5–44 45–59 60+ Total mean age (in years) Mean age for female Mean age for male Gender Female Male Marital status Never married Married Cohabitation Divorced/separated Widowed Employment status Employment Unemployment Student Housewife Living situation Solitary Shared accommodation Living with family Cohabitation Annual income of family Low (≤10 000) Medium (10 001–50 000) High (N50 000) Educational level Elementary school High school College Religious beliefs No Yes

P

With psychiatric disorders n%

34 (46.6) 31 (42.5) 5 (6.8) 3 (4.1) 29.86±14.29

46 (27.7) 90 (54.2) 22 (13.3) 8 (4.8) 33.69±13.69

.03*

.05*

30.36±12.88 28.06±18.90

33.08±12.74 35.83±16.61

.18 .14

57 (78.1) 16 (21.9)

129 (77.7) 37 (22.3)

.95

29 (39.7) 33 (45.2) 10 (13.7) 0 (0) 1 (1.4)

61 (36.7) 72 (43.4) 12 (7.2) 13 (7.8) 8 (4.8)

.04*

47 (64.4) 11 (15.1) 12 (16.4) 3 (4.1)

85 55 16 10

(51.2) (33.1) (9.6) (6.0)

.01*

1 (1.4) 10 (13.7) 51 (69.9) 11 (15.1)

18 (11.5) 16 (10.3) 120 (76.9) 2 (1.3)

.02*

10 (13.7) 44 (60.3)

35 (21.1) 82 (49.4)

.24

19 (26.0)

49 (29.5)

44 (60.3) 22 (30.1) 7 (9.6)

89 (53.6) 46 (27.7) 31 (18.7)

.20

68 (93.2) 5 (6.8)

151 (91.0) 15 (9.0)

.57

psychiatric disorders (92.2% and 91.8%, respectively) and the majority of patients who overdosed used psychotropic drugs (Table 2). No significant difference was observed between the two groups. Histories of a previous suicide attempts were not statistically significant between groups (P=.12). A positive family history of suicide attempts was also not significantly different between groups (P=.26). There were no significant differences between the two groups in their alcohol use at the time of the episode or up to 12 h before. There were also no significant differences between the two groups in writing a suicide note and making funeral arrangements. Those without psychiatric diagnoses had significantly more self-rescue ideation compared to the psychiatric group

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Table 2 Clinical characteristics of the suicide attempters Characteristics

Without any With psychiatric P psychiatric disorders disorders N%

Table 3 Psychiatric disorders of suicide attempts in emergency department of 4 general hospitals in Shenyang, China (primary diagnose considered) Man (N=37)

N%

Method of suicide attempts Self-poisoning 67 (91.8) 153 (92.2) Self-injury 5 (6.8) 12 (7.2) Other 1 (1.4) 1 (0.6) Previous episodes of suicide attempts No 60 (82.2) 121 (72.9) Yes 13 (17.8) 45 (27.1) Family history of suicide attempts No 72 (98.6) 159 (95.8) Yes 1 (1.4) 7 (4.2) Alcohol use at the time of the episode or up to 12 h before No 66 (90.4) 145 (87.3) Yes 7 (9.6) 21 (12.7) Self-rescue No 61 (83.6) 160 (96.4) Yes 12 (16.4) 6 (3.6) Impulsive suicide attempts No 31 (42.5) 101 (60.8) Yes 42 (57.5) 65 (39.2) Motive of suicide attempt Deceased pain and burden 30 (41.1) 101 (60.8) Threatened others 33 (43.8) 41 (24.7) Other 10 (15.1) 22 (14.5) Suicide note No 68 (93.2) 148 (89.2) Yes 5 (6.8) 18 (10.8) Funeral arrangements No 71 (97.3) 161 (97.0) Yes 2 (2.7) 5 (3.0) Seeking for help No 56 (76.7) 132 (79.5) Yes 17 (23.3) 34 (20.5) Score on SIS 13.84±19.45 39.99±19.84 Score on HAMA 8.44±5.77 24.34±11.08 Score on life quality 20.06±2.50 16.78±2.84

.83

.12

.26

.50

.001*

.001*

.008*

.34

Any Axis I diagnoses Mood disorders Major depression Dysthymia Depression disorder NOS Depression due to GMC Depression due to substance Anxiety disorders Specific phobia Posttraumatic stress disorder Anxiety disorder NOS Psychotic disorders Schizophrenia Schizophreniform disorder Schizoaffective disorder Brief psychotic disorder Psychotic disorder due to substance Psychotic disorder NOS Substance-related disorders Somatoform disorders Adjustment disorders

Woman (N=129)

P

N

%

N

%

23 10 1 10 1 1 2 0 0 2 7 2 1 0 0 3

62.2 27.0 2.7 27.0 2.7 2.7 5.4 0.0 0.0 5.4 18.9 5.4 2.7 0.0 0.0 8.1

81 44 4 32 1 0 24 1 1 21 11 6 0 2 1 0

62.8 34.1 3.1 24.8 0.8 0.0 18.6 0.8 0.8 16.3 8.5 4.7 0.0 1.6 0.8 0.0

1 4 1 0

2.7 10.8 2.7 0.0

2 2 1 11

1.6 1.6 0.8 8.5

.01* .94

.09

.07

.03* .93 .02*

GMC, general medicine condition.

3.3. Prevalence of mental disorder in suicide attempters .91

.63 .001* .001* .001*

SIS, Suicide intent scale; HAMD, Hamilton depression scale.

(16.4% and 3.6%, P=.001). Compared to the suicide attempts with mental disorder group, the group without mental disorders manifested more aggressive/impulsive traits, as reflected by taking actions to suicide in less than 2 h (P=.001). Comparing the motives for suicide attempts of the two groups revealed a difference that was statistically significant (P=.008). The patients with mental disorders are more likely to decrease the pain and the burden and those without mental disorders are more likely to threaten others. The results indicated that suicide attempters with psychiatric disorders had significantly greater intensity of suicidal ideation at the time of the interview (P=.001). The clinicians' ratings of depression, using the Hamilton depression scale, were significantly higher for suicide attempters with psychiatric disorders than for suicide attempters without psychiatric disorders (P=.001). Score on life quality was greater in suicide attempters without psychiatric disorders than in suicide attempters with psychiatric disorders (P=.001).

One hundred and sixty-six subjects (69.5%) met the criteria for an axis I disorder (Table 3). There were significant differences in the rates of any diagnoses between men and women (P=.01). Mood disorder was the most common psychiatric diagnosis in both groups (62.2% among men and 62.8% among women), followed by psychotic disorders, substance-related disorders and anxiety disorders among men. Among women, substance-abuse related disorders were less common than in men and anxiety disorders are more common than in men. Male patients were significantly more likely to suffer from substance-related disorders (P=.03). No significant gender difference was

Table 4 Result of logistic regression analysis: 73 suicide attempts without psychiatric disorders and 166 suicide attempts with psychiatric disorders as a dependent variable Independents Continuous variables Score on SIS Score on HAMA Score on life quality Dichotomous variables Gender Educational years 0–6 years N6 years

Significance

Odds ratio (95%CI)

0.02 0.01 0.01

1.01 (1.00-1.03) 1.26 (1.16-1.37) 0.75 (0.63-0.90)

0.02

3.67 (1.23-10.91)

0.01

1.19 (1.04-1.36)

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found in the prevalence of anxiety disorders. The most common anxiety disorder was anxiety NOS (16.3% vs. 5.4% respectively). Adjustment disorders were present in 11 patients (8.5%), with all female patients (P=.02). 3.4. Result of logistic regression analysis A logistic regression model examined factors associated with a psychiatric diagnosis among suicide attempters, with presence of a psychiatric diagnosis as the dependent variable. Multivariate logistic regression analysis identified the following independent predictors of having a current psychiatric disorder in the suicide attempters: female gender (OR=3.67, 95% CI=1.23–10.91), more than 6 years of formal education (OR=1.19, 95% CI=1.04–1.36), a higher score on the suicide ideation scale (OR=1.01, 95% CI=1.00–1.03), a higher score on Hamilton depression rating scale (OR=1.26, 95% CI=1.16–1.37) and a lower score on the quality of life scale (OR=0.75, 95% CI=0.63-0.90) (Table 4). 4. Discussion To the best of our knowledge, this is one of the few studies about the psychiatric assessment of suicide attempts in emergency department of general hospitals yet available in mainland China. The sample is representative of emergency outpatients at general hospitals in a large urban municipality in northern China, the diagnosis was based on the administration of SCID by trained researcher who had excellent inter-rater reliability, the assessment of mental illness was based on clinical structured interview and standardized instruments rather than on psychological autopsy study, and rigorous quality control measures were enforced throughout the study. There are, however, some limitations that should be considered when interpreting the results. The emergency department is a busy and sometimes chaotic environment; thus, many emergency physicians may not have time to fully screen patients for mental health issues. As a result, the mental health concerns of emergency department patients are often not recognized or addressed properly [21,22]. In China, most patients with suicide attempts could not receive a psychiatric assessment. The rate of psychiatric disorders found in this study suggests that the assessment of suicide attempts should include careful screening for psychiatric symptoms. 4.1. Main findings The present study investigated the socio-demographic characteristics, the clinical characteristics and DSM-IV Axis I diagnoses of suicide attempters admitted to emergency department of general hospitals. The proportion of females was much higher than that of males and the main method was ingestion of psychoactive drugs. Other factors included history of prior attempts and use of alcohol at the time of attempts, and the most frequent mental disorders were mood disorders. These results are

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similar to prior studies [23–27] and also indicate that significant differences in demographic and clinical variables exist between patients with and without psychiatric disorders who attempt suicide. Most suicide attempts of patients without psychiatric disorders included adolescents, manifesting impulsive traits, and were associated with wanting to threaten others and make others feel guilty, having significant more self-rescue ideation and wanting to get help. The finding was in contrast to that of Zhang et al [28], who did not find the differences between the suicides with and without psychiatric diagnoses. However, sample and method differences may not account for the findings, as the Zhang et al study used the sample of completed suicide and the method of case-control psychological autopsy study. 4.2. Differences of suicide attempters with and without mental disorders Among the social demographic parameters considered, an influential one associated with attempted suicide was age. A majority of suicide attemptors without mental disorders in this study were between the ages of 15 and 24 years and the larger proportion of suicide attemptors with mental disorders were between the ages of 25 and 44 years. The rates of psychiatric disorder of youth suicide attempts and adult suicide attempts (57.5% vs. 75.5%) found in this study is consistent with the Chinese psychological autopsy study (45% vs. 66%) [29]. However, these are different from those reported in western countries where among adolescents who completed suicide, more than 90%suffered from associated psychiatric disorders at the time of their death [30]. Mood disorders, anxiety disorders, substance abuse and disruptive disorders convey the highest risk for suicide and the presence of multiple disorders is associated with especially elevated risks [31]. These data suggest that in China youth suicide attempts have a lower prevalence of mental disorders. Those who are at the stage of physiological and psychological transformation from childhood to adulthood are probably may not be equipped to cope with these psychosocial challenges [32]. 4.3. Current psychiatric diagnosis of suicide attempters Our findings that 69.5% of the patients who attempted suicide had psychiatric disorders are lower than the rate found in a study of Japanese suicide attempters that also used DSM-IV Axis I diagnoses criteria. In their study, 81% of attempted suicide cases had an axis I diagnosis and mood disorders were also the most common [33]. The rate of mental disorders among suicide attempters in the current study was much lower than those documented in prior studies among clinical samples and those dying by suicide in western developed countries [34,35]. Our finding of a lower rate of mental disorders among suicide attempters is consistent with a Chinese study indicating that of 326 people who had carried out serious but non-

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fatal acts of self harm in China, only 40% had a diagnosable mental illness, and 35%reported that they first considered harming themselves 10 minutes or less before making the attempt [36,37]. The current study also found that 44.8% suicide attempters had impulsive and aggressive traits, as reflected in taking actions to suicide in less than 2 h. Our finding is also consistent with several recent studies that suggest that mental disorders are less important in the occurrence of suicidal behaviors in developing countries relative to developed countries [10,38]. According to Nock et al., although several consistent risk factors for suicidality emerged cross-nationally, an exception was that mood disorders were the strongest diagnostic predictors in developed countries while impulse-control disorders were the strongest predictors in developing countries [39]. The reason for the difference in the importance of impulse-control disorders between developed and developing countries is unclear and awaits further examination. 4.4. Predictor of suicide attempters with mental disorder Multivariate analysis indicated that the key factors associated with a psychiatric diagnosis among suicide attempters in emergency departments were female gender, lower level of education, suicidal ideation, depressive symptoms and lower life quality. Scores on Hamilton Rating scale for depression may be associated with psychiatric disorders and increase the likelihood of suicidal acts when an individual is feeling hopeless because of depression or other disorders and is facing seemingly insurmountable problems. The data also suggests that the increasing suicidal ideation questionnaire scores were associated with the current psychiatric disorder of suicide attempters [40]. If the mental health services are limited, this could be particularly important for maximally facilitating the next steps: recognition of mental disorders and treatment engagement. 4.5. Limitation One limitation of the present study is that the findings are based on a relatively small sample in one regional hospital, raising the question of whether the results can be generalized. The second is that we had limited data on suicide attempters who did not participate in our study. The third is that our study cohort was limited to an urbanbased population. Different outcomes may be expected in a rural-based population. Thus, a multicentre study focusing on multiple sites is required to demonstrate current trends in attempted suicide in China. The fourth is that our study only assessed Axis I diagnoses. We did not assess Axis I diagnoses and may have underestimated this comorbidity. Despite these limitations, the present study provides evidence helpful in understanding the characteristics of nonfatal suicide attempters in China and has implications for prevention.

4.6. Conclusion This study is a comprehensive evaluation of consecutive patients admitted to hospitals because of medical injury sustained due to a suicide attempt. Suicide attempters with and without mental illnesses are distinct on a number of important dimensions. Mental health assessment and appropriate discharge planning for patients treated in emergency departments for suicide attempts are crucial components of comprehensive suicide prevention efforts. Acknowledgments This project was part of the “Small Grants Program to Improve the Quality and Implementation of Suicide Research in China” which was supported by the China Medical Board of New York (grant number 05-813) and coordinated by Professor Michael Phillips of the Shanghai Jiao Tong University School of Medicine. We would like to thank the four participating hospitals in Shenyang for their active support of the project; Wang Zhiqing, Jiang Chunling from the Beijing Suicide Research and Prevention Center at the Beijing Hui Long Guan Hospital for their assistance in coordinating the project. References [1] WHO. Death and DALY estimates for 2004 by cause for WHO Member States. http://www.who.int/healthinfo/bod/en/index.html (accessed May 28, 2009). Department of Measurement and Health Information, 2009. [2] Yip PS, Liu KY, Law CK. Years of life lost from suicide in China, 1990-2000. Crisis 2008;29(3):131–6. [3] Brent DA, et al. Psychiatric risk factors for adolescent suicide: a casecontrol study. J Am Acad Child Adolesc Psychiatry 1993;32 (3):521–9. [4] Fawcett J, et al. Time-related predictors of suicide in major affective disorder. Am J Psychiatry 1990;147(9):1189–94. [5] Shaffer D, et al. Psychiatric diagnosis in child and adolescent suicide. Arch Gen Psychiatry 1996;53(4):339–48. [6] Harris EC, Barraclough B. Suicide as an outcome for mental disorders. A meta-analysis. Br J Psychiatry 1997;170:205–28. [7] World Health Organization Multisite intervention study on suicidal behaviours SUPRE-MISS Geneva. Available at: http://www.who.int/ mental_health/media/en/254.pdf, 2002. [8] Beautrais AL. Suicides and serious suicide attempts: two populations or one? Psychol Med 2001;31(5):837–45. [9] Pokorny AD. Prediction of suicide in psychiatric patients. Report of a prospective study. Arch Gen Psychiatry 1983;40(3):249–57. [10] Nock MK, et al. Cross-national analysis of the associations among mental disorders and suicidal behavior: findings from the WHO World Mental Health Surveys. PLoS Med 2009;6(8):e1000123. [11] Mann JJ, et al. Suicide prevention strategies: a systematic review. JAMA 2005;294(16):2064–74. [12] Phillips MR, et al. Risk factors for suicide in China: a national casecontrol psychological autopsy study. Lancet 2002;360(9347): 1728–36. [13] Beck AT, Kovacs M, Weissman A. Assessment of suicidal intention: the Scale for Suicide Ideation. J Consult Clin Psychol 1979;47 (2):343–52. [14] Williams JB. A structured interview guide for the Hamilton Depression Rating Scale. Arch Gen Psychiatry 1988;45(8):742–7.

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